ORIGINAL RESEARCH
published: 21 December 2020
Edited by:
Fang Hua,
Wuhan University, China
Reviewed by:
Faris Hasan al Lami,
University of Baghdad, Iraq
Armelia Sari Widyarman,
Trisakti University, Indonesia
*Correspondence:
Sarhang S. Gul
sarhang.hama@univsul.edu.iq
orcid.org/0000-0003-1413-4934
Specialty section:
This article was submitted to
Infectious Diseases - Surveillance,
Prevention and Treatment,
a section of the journal
Frontiers in Medicine
Received: 14 August 2020
Accepted: 02 December 2020
Published: 21 December 2020
Citation:
Mahdee AF, Gul SS, Abdulkareem AA
and Qasim SSB (2020) Anxiety,
Practice Modification, and Economic
Impact Among Iraqi Dentists During
the COVID-19 Outbreak.
Front. Med. 7:595028.
doi: 10.3389/fmed.2020.595028
Frontiers in Medicine | www.frontiersin.org
doi: 10.3389/fmed.2020.595028
Anxiety, Practice Modification, and
Economic Impact Among Iraqi
Dentists During the COVID-19
Outbreak
Anas F. Mahdee 1 , Sarhang S. Gul 2*, Ali A. Abdulkareem 3 and Syed Saad B. Qasim 4
1
Department of Restorative and Aesthetic Dentistry, College of Dentistry, University of Baghdad, Baghdad, Iraq,
2
Department of Periodontics, College of Dentistry, University of Sulaimani, Sulaimani, Iraq, 3 Department of Periodontics,
College of Dentistry, University of Baghdad, Baghdad, Iraq, 4 Department of Bioclinical Sciences, Faculty of Dentistry, Kuwait
University, Safat, Kuwait
Objectives: As health care workers on the front line during the coronavirus (COVID-19)
pandemic, dental practitioners are amongst those at risk due to their close contact with
potentially infected individuals. The aim of the current study was to assess the anxiety,
awareness practice modification, and economic impact amongst Iraqi dentists whilst
working during the outbreak.
Methods: This study was performed using an online survey questionnaire with aid
of Google forms from 2nd to 23rd July 2020. A total of 484 clinicians responded.
The questionnaire was composed of open end, closed end, and Likert five-point
scale questions to assess anxiety, awareness and financial impact of COVID-19 on
dentists. Mann–Whitney test was used to compare two groups, whilst Kruskal–Wallis
was performed by post-hoc test for multigroup comparisons.
Results: The mean age of participants was 36.51 ± 9.164 years and the majority
(75.2%) of these were graduate dentists only. More than 80% of participants reported
anxiety of catching COVID-19. The recorded anxiety level was higher amongst younger
dentists and females. Awareness and practice levels among these dentists of precautions
and infection-control measures associated with COVID-19 (94%) was found to be high
and to be statistically significantly affected by age, qualification and designation (except
GP vs. Specialist). With respect to the economic impact, about 75% of practitioners,
regardless of demographical variables, reported that their income had declined by
about 50%.
Conclusions: The investigation provides clear insights into the anxiety, practice
modifications and economic impact on dentists working in Iraq. Although there is a high
level of knowledge and awareness of required practice regarding the COVID-19 outbreak
among Iraqi dentists, they also reported a high level of anxiety.
Keywords: anxiety, coronavirus, Iraqi dentists, economic, practice management
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Mahdee et al.
INTRODUCTION
Since the emergence of the novel coronavirus disease (COVID-
19) in Wuhan, China, all aspects of life have been influenced
worldwide. The COVID-19 pandemic has spread in an
exponential manner (1, 2), affecting millions of people worldwide
and causing hundreds of thousands of deaths (3). Many countries
have shut down their teaching institutes, industries, sport
activities, social gatherings, public events, and airports. Drastic
measures such as individual self-quarantine and social distancing
rules have been introduced in an attempt to control the spread of
the infection (4). The condition in Iraq has been no better than in
many other countries. Since the first registered case of COVID-19
was recorded on the 24th of February 2020 in an Iranian student
attending the city of Najaf in the south of Iraq, the spread of the
virus has been escalating and as of 1st of July there were 51,524
confirmed cases and 2,050 deaths.
COVID-19 belongs to the Coronaviridae virus family, which
is characterized by a single strand RNA structure (5). This
virus has potential to cause severe respiratory tract infection
and pneumonia among infected individuals, and can be
easily transmitted via hand contact, saliva, nasal droplets and
contaminated surfaces (2, 6). Health care workers and dentists in
particular are categorized as at high risk of catching this infection
(7). This could be because their close contact with patients
during routine dental procedures increases the possibility of
infection transmission (8, 9). Droplets and aerosols that are
generated during dental procedures by such as high speed
handpieces, air-water syringes, and ultrasonic scaling could
produce a contaminated pathogenic environment within the
dental working field during treatment of an infected person
(6, 9, 10). Therefore, the risk of infection transmission within the
dental team cannot be controlled through the standard protective
measures of daily dental practice (8). This categorization as
high-risk professionals could increase fear within the dental
community (11, 12).
Regarding the rapid spread of the infection, the World Health
Organization (WHO) and American Dental Association (ADA)
published specific precaution guidelines to be implemented
by dentists during treatment of urgent and emergency cases
only. Otherwise, they stipulated that dental offices should be
kept closed during the outbreak (13, 14). These guidelines
emphasized the use of the appropriate precautions including
wearing personal protective equipment (PPE) during dental
procedures (13, 14). In addition, the use of antibacterial mouth
washes, rubber dam, and high-volume section during treatment
procedures with frequent cleaning and disinfecting of surfaces of
chairs, door handles and floors was highly recommended (8, 15).
Providing a secure environment is of paramount importance for
dentists and dental staff to conduct dental work in a safe working
environment. The high infection rate of COVID-19 and lack of
PPE might affect the anxiety of the dentist. The levels anxiety
of dentists have shown a negative impact on decision making,
quality of work, and burnout (16).
On the other hand, in dental practice the demand arose
for more expensive aerosol controlling equipment such as the
high efficiency particulate arrestor (HEPA) during the outbreak
Frontiers in Medicine | www.frontiersin.org
Impact of COVID-19 Among Dentists
period (10). The expense of these precautionary measures and
limitations in the treatment of patients may have had serious
economic impact on the dentistry field. Hence, the future careers
of dentists could be affected if the outbreak continues for an
indefinite period.
Meanwhile, no study has assessed the levels of anxiety among
Iraqi dentists in the wake of the COVID-19 outbreak, their
awareness about this illness and the infection control guidelines
to prevent its spread, or the financial impact on their current
practice. Therefore, the aim of this study was to use a specially
designed online-based questionnaire to assess the impact of
the COVID-19 outbreak on Iraqi dentists in terms of their
anxiety, awareness and practice modification, and the financial
implications for their dental practice.
METHODS
Survey Administration
A cross-sectional survey was conducted using an online
questionnaire that was electronically sent to Iraqi dentists by Iraqi
Dental Association (IDA). Administration of the questionnaire
started on 02/07/2020 for a period of 2 weeks, which was
extended for another week after a reminder was sent, and ended
on 23/07/2020. The study was approved by the ethics committee
of the College of Dentistry, University of Baghdad in compliance
with the Helsinki declaration (Ref No. 579/06/2020).
Study Population and Sample Size
The survey was exclusively sent to registered Iraqi dentists
and only completed forms were included in the final analysis.
All incomplete forms and those returned outside the required
timeframe were excluded.
The total number of registered Iraqi dentists, as officially
provided by the IDA, was 6,463. Sample size was determined
according to the following formulas (17, 18):
Sample size = (distribution of 50%)/[(margin of error%/
confidence level score)2 ]
Confidence level = 1.96 (for confidence level of 95%),
margin of error = 0.05.
True sample = (sample size × population)/
(sample size + population − 1)
The calculated sample size was equal to 363 which was further
adjusted to take account of the dropout risk, previously estimated
from a pilot study, by using the following formula:
N = n/[1 − (z/100)]
Where N is the adjusted sample size, n is the calculated sample
size, z represents the hypothesized attrition rate (25%). The
final sample size was equal to 484 dentists. Accordingly, the
questionnaire link was distributed via emails to corresponding
number of randomly selected dentists.
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Mahdee et al. Impact of COVID-19 Among Dentists

TABLE 1 | The study questionnaire.

Age
Country

Sex A-Male B-Female

Qualification A-Graduate B-Postgraduate
Designation A-General practitioner B-Specialist C-Consultant
Working place A-Clinic B-Hospital C-Both
Working type A-Private B-Government C-Both

1- Do you have a anxiety of being infected with COVID-19 by a patient or co-worker? Yes No
2- Are you afraid of providing treatment for any patient? Yes No
3- If a patient is coughing or suspected to be infected with COVID-19, are you afraid to provide treatment for him/her? Yes No
4- Do you anxious talking to the patients in close proximity? Yes No
5- Are you afraid that you could carry the infection from your practice back to your family? Yes No
6- Do you feel anxious when you hear that one of your co-workers or colleagues has been infected with COVID-19? Yes No
7- Do you know the illness problems associated with COVID-19 virus? Yes No
8- Do you know the mode of transmission of COVID-19 virus? Yes No
9- Are you updated with the current WHO guidelines for cross-infection control for COVID-19 virus? Yes No
10- Are you currently asking every patient if he/she has recently been in contact with an infected COVID-19 person? Yes No
11- Are you or your staff members taking every patient’s body temperature before performing dental treatment? Yes No
12- Are you deferring dental treatment for patients with suspicious symptoms? Yes No
13- Do you think the routine surgical mask is effective to prevent COVID-19 cross infection? Yes No
14- Do you think that N-95 masks should be used routinely in dental practice because of the current COVID-19 outbreak? Yes No
15- Do you routinely follow universal infection control protocol for every patient? Yes No
16- Do you currently use rubber dam isolation for every patient as a part of your infection control? Yes No
17- Do you routinely use high volume section for every patient as part of droplets and airborne isolation precautions? Yes No
18- Do you routinely prepare antimicrobial mouth rinse for every patient to be used before starting treatment? Yes No
19- Have you changed or increased the procedure of infection control during the COVID-19 pandemic? Yes No
20- Has the schedule of your practice been changed to make it safer for you and the patient? Yes No
21- Do you routinely wash your hands with soap and water/ use sanitizer before and after treatment of every patient? Yes No
22- Do you and your staff members get tested for COVID-19 as a precautionary measure? Yes No
23- Do you know which authority to contact if you come across a patient with suspected COVID-19 infection? Yes No
25- What is the average drop in the number of patients visiting your practice as compared to the period before the COVID-19 pandemic?
A- N/A B- <25% C- 25–50% D- 50–75% E- >75%
26- How many appointments for non-urgent cases have you canceled recently as a part of COVID-19 precaution protocol?
A- N/A B- <25% C- 25–50% D- 50–75% E- >75%
27- Because of the COVID-19 pandemic, how much have the prices for your dental services been reduced, if at all?
A- N/A B- <25% C- 25–50% D- 50–75% E- >75%
28- If any, how much financial compensation (governmental and non-governmental) are you receiving for your losses in your practice?
A- N/A B- <25% C- 25–50% D- 50–75% E- >75%
29- To what extent have you reduced the staff numbers in your clinic?
A- N/A B- <25% C- 25–50% D- 50–75% E- >75%
30- By how much has the practice’s income been reduced due to the COVID 19 pandemic?
A- N/A B- <25% C- 25–50% D- 50–75% E- >75%
31- What percentage of your stored dental materials have expired during the COVID-19 pandemic?
A- N/A B- <25% C- 25–50% D- 50–75% E- >75%
32- If applicable, what has been the average reduction of working days during the COVID-19 outbreak?
A- N/A B- <25% C- 25–50% D- 50–75% E- >75%

Questionnaire Design
Google forms was used to create the link for the questionnaire
(illustrated in Table 1) that was distributed to the targeted
population electronically via IDA to ensure uniform and
validated distribution across all groups of dentists, including
general practitioners, specialists, and consultants, throughout
the country. Before distributing the questionnaire, a pilot study
was conducted which included 36 dentists (about 10% of the
sample size). Then data were entered on spreadsheet and
double-checked by two authors which was followed pre-launch
analysis was performed to check the internal consistency of all
questionnaire’s components.

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Mahdee et al. Impact of COVID-19 Among Dentists

The questionnaire was adapted and modified from previously TABLE 2 | Demographic characteristics of the study population.
published surveys (19, 20). The questionnaire used for this study
AGE (YEARS)
was composed of demographic/practice-related, closed end, and
(mean± SD) 36.51 ± 9.16
Likert five-point scale questions. These questions were divided
Age range 23–70
into four sections:
AGE GROUPS (YEARS)
Section 1 was designed to collect demographic/practice-related ≤35 222 (51)§
variables of the respondents. >35 213 (49)§
Section 2, questions #1 to #6, was intended to assess the anxiety Gender
among dentists deriving from the COVID-19 infection. Male 218 (50.1) §
Section 3, questions #7 to #23, was designed to evaluate Female 217 (49.9)§
the dentists’ awareness and practice modification about QUALIFICATION
the precautions and infection-control measures for Graduate 327 (75.2)§
COVID-19 infection. Postgraduate 108 (24.8)§
Section 4, questions #24 to #32, consisted of questions that DESIGNATION
explored the economic impact of COVID-19 on dental practice. General practitioner 208 (47.8)§
For closed end questions, each positive response “Yes” was Specialist 206 (47.4)§
marked as “1” while “No” was marked with “0.” The frequency Consultant 21 (4.8)§
of the positive/negative responses was used to assess the dentists’ WORKPLACE
anxiety (section 2) and awareness (section 3) regarding the Clinic 202 (46.4)§
COVID-19 infection. For section 4, the responses “N/A,” “<25%,” Hospital 70 (16.1)§
“25–50%,” “50–75%,” “>75%” received sequential scores of “1,” Both 163 (37.5)§
“2,” “3,” “4,” “5,” respectively. The scores for each section were EMPLOYMENT TYPE
summed together to calculate the mean of the answers to evaluate Private 135 (31.1)§
the response according to the different independent variables. Governmental 98 (22.5)§
Both 202 (46.4)§
Statistical Analysis Total 435 (100)§
Demographic data and total responses for each question were
§ Frequency, percentage.
analyzed by descriptive statistics expressed by mean, standard
deviation, and frequency/percentage. Inferential analysis for
sections 2, 3, and 4 was performed by using Mann–Whitney
test for comparing two groups while Kruskal–Wallis followed
by post-hoc test was used for multiple groups comparisons. The aggravated (397, 91%) if a patient was showing a sign of suspected
statistically significant value was set at p < 0.05. All analyses were infection such as coughing (Q3). Moreover, about 72% (316) of
performed by using GraphPad Prism (Version 8.4.3, GraphPad the respondents were not comfortable with being in close contact
Software, San Diego, CA, USA). with their patients (Q4). The highest scoring response among
the participants (413, 94%) was associated with the anxiety of
RESULTS carrying infection home to their family (Q5), whilst the second
highest response (395, 90%) related to hearing that a co-worker
A total of 435 dentists (218 male and 217 female) with mean had been infected with COVID-19 (Q6).
age of 36.51 ± 9.164 years (ranging from 23 to 70 years) Regarding responses to section 3 questions, the dentists’
participated in the study (Table 2). The number of respondents highest scores related to their knowledge about the COVID-19
represented 89.9% of the calculated sample size (484) after illness (Q7, 413, 94%) (Figure 1B) and its modes of transmission
excluding 49 dentists who did not response to the questionnaire (Q8, 424, 97%), modification in infection control procedure
within the specified time. The number of the respondents (435) (Q19, 410, 94%) re-scheduling patients’ appointments (Q20, 404,
was considered as a satisfactory response rate (89.8%). The 93%), and washing hands before and after treatment (Q21, 416,
majority of respondents (327, 75.2%) were graduate dentists, in 95%). Additionally, three questions achieved (>80%) positive
comparison to 108 (24.8%) who had postgraduate degrees. The responses including: the dentist had updated information
proportions of general practitioners, specialists and consultants about the current WHO guidelines for infection control (Q9),
were 47.8% (208), 47.4% (206), and 4.8% (20), respectively. deferring treatment of patients with suspicious symptoms
Furthermore, 202 (46%) of respondents working in clinics (12), and following universal infection control protocol (Q15).
worked in both the private and governmental sector (Table 2). Whereas, the lowest awareness score (138, 31.7%) related to the
Responses to section 2 questions relating to dentists’ feelings effectiveness of surgical masks to prevent cross infection (Q13),
about the COVID-19 pandemic indicated that the majority of in comparison to nearly 80% of respondents who thought that
respondents (386, > 80%) (Figure 1A) were anxious of catching N95 masks should be used routinely in dental practice (Q14). The
the COVID-19 infection (Q1). Over 60% (274) of the dentists response to (Q16) about the use of rubber dam as an infection
were afraid of treating any patients (Q2). This anxiety was further control measure was equally low at 31.7% (138), but a higher

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Mahdee et al.
FIGURE 1 | Dentists’ responses to anxiety and awareness questions: (A) responses to individual questions on anxiety of COVID-19 and (B) awareness of precaution
and infection control-measures.
percentage of respondents (265, >60%) confirmed that they used
high volume section as a droplets precaution measure (Q17).
The economic impact of COVID-19 was investigated in this
study via the section 4 questions (Figure 2). About 27% of
the respondents suggested that the price of personal protection
equipment had increased by >75% of the original price (Q24).
Meanwhile, 32% of the dentists indicated that the number
of patients had declined by 25–50% (Q25). The influence of
COVID-19 on income was very apparent as >75% of the dentists
reported that their income had dropped by 25–50% (Q30), with
a similar response regarding the reduction in their working
days (Q32). The level of financial compensation received by the
dentists was unsatisfactory as more than half of the respondents
were not eligible for any support programmes (Q28). However,
the majority of the respondent dentists had not decreased their
staff numbers (Q29) (Figure 2).
Frontiers in Medicine | www.frontiersin.org
Impact of COVID-19 Among Dentists
Inferential analysis of the questionnaire sections showed
that older (>35 years old) and male respondents exhibited a
statistically significant lower degree of anxiety of COVID-19
compared to younger (≤35 years old, p = 0.018) and female
(p = 0.003) respondents, respectively (Table 3). Furthermore,
the respondents who worked only in a hospital or in a
clinic and hospital showed a statistically significantly higher
anxiety than those working only in a clinic. Similarly, those
working only in the government sector or in the government
and private sector showed statistically significantly higher
anxiety from COVID-19 than those working only in private
clinics. However, respondents’ qualifications and designation
did not show a statistically significant impact on anxiety
of COVID-19 (Table 3). Generally, the mean of responses
showed a high level of anxiety of COVID-19 infection
(5.01 ± 1.37; Table 3).
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Mahdee et al. Impact of COVID-19 Among Dentists

TABLE 3 | Respondents’ anxiety of the COVID-19 infection.

Variables Mean ± SD Comparison p-value

AGE
≤35 5.14 ± 1.27 ≤ 35 vs. > 35 0.018*
>35 4.87 ± 1.45
GENDER
Male 4.78 ± 1.57 Male vs. female 0.003*
Female 5.24 ± 1.08
QUALIFICATION
Graduate 4.9 ± 1.39 Postgraduate vs. 0.363*
Graduate
Postgraduate 5.04 ± 1.36
DESIGNATION
General practitioner 4.89 ± 1.43 GP vs. Specialist 0.377†
FIGURE 2 | Dentists’ responses on the economic impact of COVID-19 (GP)
outbreak on their practice. Specialist 5.11 ± 1.34 GP vs. Consultant >0.999†
Consultant 5.23 ± 0.88 Consultant vs. Specialist >0.999†
WORKPLACE
Clinic 4.76 ± 1.45 Clinic vs. Both 0.003†
The mean awareness of respondents (section 3) was 12.65
Hospital 5.31 ± 1.08 Clinic vs. Hospital 0.015†
± 2.36 (Table 4). Age of the study participants have shown
Both 5.19 ± 1.33 Hospital vs. Both >0.999†
a statistically significant impact on respondents’ awareness,
EMPLOYMENT TYPE
whereas, this is not the case when male and female compared.
Private 4.71 ± 1.51 Private vs. Governmental 0.046†
Furthermore, qualification and designation (except for GP vs.
Governmental 5.12 ± 1.09 Private vs. Both 0.015†
Specialist) were found to have a statistically significant effect
Both 5.2 ± 1.36 Governmental vs. Both 0.064†
on respondents’ awareness (P < 0.05, Table 4). Meanwhile,
Total 5.01 ± 1.37
no statistically significant differences in respondents’ awareness
were identified according to workplace and employment type *Mann–Whitney test, †Kruskal–Wallis test.
(Table 4).
Regarding the economic impact, no demographic variables
emerged as having a statistically significant economic effect due to the quick spread of the virus, general feelings of stress
(Table 5). However, the mean economic effect was recorded as and fear among healthcare workers for their own safety and
equal to 2.72 ± 0.71 out of 5 (Table 5), i.e., the economic losses that of their families (23). Additionally, the nature of this
incurred by the dental community amounted to more than 50%. disease, with its prolonged incubation period (as long as 14
days), its spectrum that ranged from asymptomatic to death,
DISCUSSION and the absence of a vaccine or treatment, are all factors
potentially exacerbating stressful feelings among healthcare
The present cross-sectional study reported a high level of workers, especially dentists. This confirms findings from studies
anxiety among Iraqi dentists as a result of the COVID-19 about COVID-19 (11), or previous outbreaks of similar infectious
outbreak and high awareness about preventing its transmission respiratory diseases such as SARS, which demonstrated severe
and avoiding infection; in addition, they and their practices and sustained psychological trauma, especially among the front
have been economically affected due to this pandemic situation. line healthcare workers (24, 25).
These findings are understandable because dentists fall within Another interesting finding within the present study was
the highest risk category, since their practice is associated with that the recorded anxiety level was higher among younger than
generation of droplets and aerosols which is considered as a older dentists and females than males. This goes against the
main route of virus transmission (6). The high levels of anxiety reports that among infected individuals there are higher risk
recorded among these Iraqi dentists can be considered as natural groups, including older and male adults, who are more likely
human feelings during the pandemic situation, especially in to develop severe respiratory symptoms and die than younger
light of the increasing infection and mortality rates. In Iraq individuals and females (26). It may be that older dentists are
the mortality rate is considered to be higher (about 3.9%) in more experienced than younger dentists in dealing with similar
comparison to other regional countries, such as the UAE with pandemic situations. This may make them more confident and
only a (0.5%) mortality rate (3). This could possibly be due less prone to anxiety. This was also reflected in the finding by this
to differences in available health resources between these two study of a statistically significant higher level of awareness about
countries (21). The general weakness in the medical foundations the virus and its mode of transmission among dentists aged above
and care system in Iraq after four decades of military conflicts 35 years in comparison to those aged below 35 years. Moreover,
(22), and the exaggerated pressure on the health care system since females, as mothers, tend to have closer contact with their

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Mahdee et al. Impact of COVID-19 Among Dentists

TABLE 4 | Respondents’ awareness of COVID-19 infection-control measures. TABLE 5 | Economic impact of the COVID-19 outbreak.

Variables Mean ± SD Comparison p-value Variables Mean ± SD Comparison p-value

AGE AGE
≤35 11.14 ± 2.41 ≤35 vs. >35 <0.001* ≤35 2.71 ± 0.69 ≤ 35 vs. > 35 0.955*
>35 12.99 ± 2.24 >35 2.72 ± 0.72
GENDER GENDER
Male 12.32 ± 2.58 Male vs. female 0.121* Male 2.67 ± 0.72 Male vs. female 0.109*
Female 12.8 ± 2.09 Female 2.77 ± 0.69
QUALIFICATION QUALIFICATION
Graduate 11.98 ± 2.49 Postgraduate vs. 0.003* Graduate 2.66 ± 0.8 Postgraduate vs. 0.468*
Graduate Graduate
Postgraduate 12.75 ± 2.28
Postgraduate 2.73 ± 0.67
DESIGNATION
DESIGNATION
General practitioner 12.48 ± 2.24 GP vs. Specialist >0.999†
General practitioner 2.71 ± 0.73 GP vs. Specialist 0.463†
(GP)
(GP)
Specialist 12.53 ± 2.48 GP vs. Consultant 0.016†
Specialist 2.74 ± 0.65 GP vs. Consultant 0.463†
Consultant 13.91 ± 1.92 Consultant vs. Specialist 0.027†
Consultant 2.54 ± 0.94 Consultant vs. Specialist 0.353†
WORKPLACE
WORKPLACE
Clinic 12.76 ± 2.07 Clinic vs. Both 0.569†
Clinic 2.73 ± 0.73 Clinic vs. Both >0.999†
Hospital 12.44 ± 2.58 Clinic vs. Hospital 0.963†
Hospital 2.68 ± 0.67 Clinic vs. Hospital >0.999†
Both 12.36 ± 2.58 Hospital vs. Both >0.999†
EMPLOYMENT TYPE Both 2.71 ± 0.69 Hospital vs. Both >0.999†

Private 12.82 ± 2.09 Private vs. Governmental 0.196† EMPLOYMENT TYPE

Governmental 12.26 ± 2.38 Private vs. Both >0.999† Private 2.63 ± 0.74 Private vs. Governmental >0.999†
Both 12.53 ± 2.52 Governmental vs. Both 0.674† Governmental 2.69 ± 0.67 Private vs. Both 0.077†
Total 12.65 ± 2.36 Both 2.79 ± 0.69 Governmental vs. Both 0.877†
Total 2.72 ± 0.71
*Mann–Whitney test, † Kruskal–Wallis test.
*Mann–Whitney test, † Kruskal–Wallis test.

children than other family members, the anxiety of transferring

infection to family members, especially their children, could
increase feelings of stress among female in comparison to male
dentists. In the same way, dentists who were working in the
public sector, in clinics or hospitals, reported higher anxiety levels
than others. This could be attributed to the large number of
dental patients visiting the public centers per day in comparison
to private clinics (27). Consequently, this may increase dentists’
concerns and anxiety of being infected compared to those
working only in private clinics, who have more control over their
appointments, case selection and cancellation of non-emergency
cases. Finally, consultant dentists and those with postgraduate
degree have higher levels awareness than their counterparts
and this can be explained by the fact the majority of these
dentists work in academic field, thus more update about the new
developments in their field including the COVID-19 outbreak.
Almost all of the responding dentists were aware of the nature
of the COVID-19 illness and its mode of transmission. This
information is considered to be crucial in terms of applying
infection control measures while carrying out dental treatment.
In the same way, over 80% of the dentists responded that
they were up to date about the current WHO guidelines for
cross-infection control measures within dental practice (14).
This was reflected through over 70% of the respondents asking
their patients if they had been in contact with an infected
COVID-19 individual, and above 60% recording patients’
body temperature. Logically, this is basic information required
during the routine examination to identify potentially infectious
conditions among patients and the necessary precautionary
management. Indeed, under such pandemic circumstances, the
conventional precautions already recommended by WHO and
any other infectious control authority worldwide should be
rigorously applied to prevent cross-infection within dental
practice. But unfortunately, more than 60% of the respondents
were not using rubber dam for every patient as a cross-infection
control. Rubber dam effectively limits the spread of aerosols
during use of rotary instruments, decreases the hazard of fine
instrument swallowing, gives excellent isolation of the working
field and increases patients’ acceptance of dental procedures
(28). Therefore, training courses and workshops are suggested
for Iraqi dentists, especially new graduates, to increase their
awareness about the effectiveness of rubber dam in controlling
the spread of infection. This could improve their hand skills and
increase their willingness to consider rubber dam as part of their
routine practice. The usage of high volume suction should also be
considered as an essential method during routine dental practice
to control aerosols and droplets evacuation (10).
The use of antimicrobial mouth washes before starting dental
procedure is also recommended in the WHO guidelines for the
current pandemic. Interestingly, over 40% of the respondents
were complying with this recommendation. Mouthwashes such
as chlorhexidine (29), 1% hydrogen peroxide (6), or povidone
iodine (30) can be employed to decrease microbial loading inside

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Mahdee et al.
the oral cavity. The latter has virucidal activity against SARS-CoV
and MERS-CoV coronaviruses and is recommended to be used at
0.5% concentration as a mouthwash for patients before initiating
a clinical procedure. Additionally, the operator is also advised
to use povidone iodine as a nasal spray (0.4%) and mouthwash
(0.5%) before and after suspected patient contact (31).
A positive finding by the current study was that the majority
of Iraqi dentists were routinely focusing on hand hygiene before
and after treating each patient, which is considered as an essential
infection control measure for dental practitioners. Frequent
hand washing with water and soap or using alcohol containing
sanitizer is included in the WHO infection control guidelines
for the current pandemic (14). The spread of respiratory viruses
can be effectively avoided by proper hand washing and cleaning
with alcohol-based sanitizers (8, 32). Furthermore, the majority
of the study respondents agreed with the routine use of N-
95 respirators rather than surgical masks in dental practice
during the COVID-19 outbreak. The use of such personal
protection equipment (PPE) is also recommended by the WHO
and ADA guidelines when performing aerosols generating
procedures (33).
Carefulness in selecting cases, controlling appointments, and
receiving only emergency cases were also recommended by
the ADA and WHO guidelines (13, 14). Almost all of the
respondents in the current study stated that they had altered
their appointment schedules to control the spread of the virus.
This process could be started by initially calling patients or
having video conferences to identify their need and decide if their
condition requires clinical intervention (34). This could help in
limiting face-to-face contact, making diagnoses through remote
dental screening, deterring any COVID-19 susceptible patients,
delaying nonemergency work, and planning effectively for the
emergency cases (8, 34).
According to the findings of the present study, the
economic losses caused by the COVID-19 outbreak to the
dental community in Iraq amounted to about 50%. This is
understandable during such a pandemic situation. The whole
country has been affected by quarantines and lockdowns in an
attempt to control the spread of the infection. The lockdowns
consisted of intermittent periods of complete closure for all
sectors followed by partial lockdown for specific sectors including
schools, universities, tourism, and others. This has had severe
economic impact on almost all activities, including dentistry
(4). Additionally, the majority of respondents in the current
study reported reduction of their working days, rescheduling
of their appointments to see emergency cases only, absence
of governmental support, and reduction in their total income.
On the other hand, as some of the study participants received
financial compensation, the degree of economic impact has
shown to be varied from one to another dentist. However, none of
demographical variables have shown an impact on income. This
can be explained by the fact that during the national lockdown,
working in private dental clinics was stopped by government
and the only source of income were their monthly salary by
the government. According to a recent investigation conducted
in the U.S., this economic impact on dental services could be
extended to 2022 because of financial hardship among dental
Frontiers in Medicine | www.frontiersin.org
Impact of COVID-19 Among Dentists
patients (35). These financial impacts on dentistry as a profession
may have serious implications for the future of this career.
The limitations of this study that should be considered is
the rapid changes in respondents’ psychology and practice in
accordance with the progression of the current outbreak, the
attitudes and awareness of dentists will certainly be altered by
future alteration in the scientific knowledge about COVID-19.
Additionally, although the distribution of the questionnaire for
the present study was done through the IDA, fewer responses
were obtained from consultants in comparison to the other
designations. This possibly because of the general panic situation
during the COVID-19 outbreak altered the priorities for potential
respondents. Thus, the findings of the current study should be
carefully interpreted to avoid generalization of the data.
CONCLUSIONS
The emergence of the novel coronavirus has increased concern
among healthcare workers, especially dentists, regarding aerosols
borne microbes rather than the conventional blood borne
microbes. This has dramatically increased the anxiety among
dentists about getting the infection and has altered their
awareness toward a new era. Although, Iraqi dentists have gained
a high level of knowledge and practice to address the COVID-19
outbreak, their anxiety was high. It is important in the current
scenario to modify the conventional dental practice to deal with
emergencies only or close down practices until the outbreak
recedes. However, this situation may last for an indefinite period,
which would have a dramatic impact not only on the economy
which have shown to affect the majority of responders by
reducing their income by 50% but also on the future of the dental
profession such as increasing levels of anxiety amongst dentist
and adapting to practice modification.
DATA AVAILABILITY STATEMENT
The raw data supporting the conclusions of this article will be
made available by the authors upon reasonable request.
ETHICS STATEMENT
The study was approved by the ethics committee of the College
of Dentistry, University of Baghdad in compliance with the
Helsinki declaration.
AUTHOR CONTRIBUTIONS
AM: study conception. AA and SG: study design. AM, AA,
SG, and SQ: data collection. AA and SG: data analysis and
manuscript drafting. AA and SG: data interpretation. SG and SQ:
critical revision of the manuscript. All authors: approval of the
final version. All authors contributed to the article and approved
the submitted version.
ACKNOWLEDGMENTS
The authors would like to thank all the dentists who responded
to this survey.
8 December 2020 | Volume 7 | Article 595028
Mahdee et al.
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Conflict of Interest: The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could be construed as a
potential conflict of interest.
The reviewer FL declared a shared affiliation with several of the authors AA
and AM to the handling editor at time of review.
Copyright © 2020 Mahdee, Gul, Abdulkareem and Qasim. This is an open-access
article distributed under the terms of the Creative Commons Attribution License (CC
BY). The use, distribution or reproduction in other forums is permitted, provided
the original author(s) and the copyright owner(s) are credited and that the original
publication in this journal is cited, in accordance with accepted academic practice.
No use, distribution or reproduction is permitted which does not comply with these
terms.
9 December 2020 | Volume 7 | Article 595028